Basic Information
| Provider Information | |||||||||
| NPI: | 1033417589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA WOMAN CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 W ATLANTIC AVE | ||||||||
| Address2: | SUITE C-304 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334453901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613002410 | ||||||||
| FaxNumber: | 5614955408 | ||||||||
| Practice Location | |||||||||
| Address1: | 7150 W 20TH AVE | ||||||||
| Address2: | SUITE 615 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055124858 | ||||||||
| FaxNumber: | 3058178309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | KONSKER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5613002410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 001553509 | 05 | FL | MEDICAID |